U.S.|Finding Good Pain Treatment Is Hard. If You’re Not White, It’s Even Harder.

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Finding Good Pain Treatment Is Hard. If You’re Not White, It’s Even Harder.

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Roslyn Lewis of Tuscaloosa, Ala., injured her back while working at a dollar store. A decade later, the pain radiates to one of her knees and remains largely unaddressed.CreditCreditIlana Panich-Linsman for The New York Times

TUSCALOOSA, Ala. — Roslyn Lewis was at work at a dollar store here, pushing a heavy cart of dog food, when something popped in her back: an explosion of pain. At the emergency room the next day, doctors gave her Motrin and sent her home.

Her employer paid for a nerve block that helped temporarily, numbing her lower back, but she could not afford more injections or physical therapy. A decade later, the pain radiates to her right knee and remains largely unaddressed, so deep and searing that on a recent day she sat stiffly on her couch, her curtains drawn, for hours.

The experience of African-Americans, like Ms. Lewis, and other minorities illustrates a problem as persistent as it is complex: Minorities tend to receive less treatment for pain than whites, and suffer more disability as a result.

While an epidemic of prescription opioid abuse has swept across the United States, African-Americans and Hispanics have been affected at much lower rates than whites. Researchers say minority patients use fewer opioids, and they offer a thicket of possible explanations, including a lack of insurance coverage and a greater reluctance among minorities to take opioid painkillers even if they are prescribed. But the researchers have also found evidence of racial bias and stereotyping in recognizing and treating pain among minorities, particularly black patients.

“We’ve done a good job documenting that these disparities exist,” said Salimah Meghani, a pain researcher at the University of Pennsylvania. “We have not done a good job doing something about them.”

Dr. Meghani’s 2012 analysis of 20 years of published research found that blacks were 34 percent less likely than whites to be prescribed opioids for conditions such as backaches, abdominal pain and migraines, and 14 percent less likely to receive opioids for pain caused by traumatic injuries or surgery.

Other studies have found that pharmacies in poor but largely white neighborhoods were 54 times as likely as those in poor minority neighborhoods to have adequate supplies of opioids, and that white children with appendicitis were almost three times as likely as black children to receive opioids in the emergency room. Black children were more likely to receive less potent, nonnarcotic medications like ibuprofen and acetaminophen, even after adjusting for pain level and other factors. And new research published this week found that blacks have significantly lower odds than whites of receiving opioids when they visit an emergency room for “nondefinitive” back or abdominal pain.

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The waiting room at a Whatley Health Services clinic in Tuscaloosa.CreditIlana Panich-Linsman for The New York Times

Adam Hirsh, a pain researcher at Indiana University-Purdue University, Indianapolis, said he had often heard what might be called a silver-lining argument: that even if blacks have been unequally treated for pain, they have largely been spared from opioid addiction. That argument does not sit well with him.

“We may agree that opioids can be harmful and that fewer of them may be a good thing,” Dr. Hirsh said. “But we should not ignore that black and white patients are getting treated differently.”

He and other researchers say the reasons may include false stereotypes, such as the assumption that blacks are more likely to abuse drugs, as well as a tendency for doctors to empathize less with patients whose race is different from their own — perhaps subconsciously — and to underestimate the severity of their pain. Only about 4 percent of the country’s practicing physicians are black.

Ms. Lewis, 50, ended up at a health center in Tuscaloosa, Whatley Health Services, which has clinics in six counties — some predominantly black, others heavily white. Deborah Tucker, Whatley’s chief executive, said the clinics’ white rural patients were the most likely to ask for and abuse opioids.

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Dr. Toya Burton, a chiropractor at Whatley Health Services, treating Robert Prince in Tuscaloosa.CreditIlana Panich-Linsman for The New York Times

“I’m not sure how to explain it,” she said.

Of course, minorities do get prescriptions for opioids, and some become addicted. Overdose deaths involving opioids are increasing across races and ethnicities, according to the Centers for Disease Control and Prevention. But in 2014, 71 out of every million white Americans died of overdoses involving prescription opioids, compared with 33 out of every million blacks.

Doctors in Alabama prescribe opioid painkillers at a higher rate than their counterparts in any other state, according to the C.D.C. Nobody tracks how those prescriptions are allocated by race. But payment data from Medicare, the government program that covers people 65 and older as well as some with disabilities, shows that in all but one of Alabama’s majority-black counties, the rate of opioid prescribing is below the state average. Four of the five Alabama counties with the lowest rates of opioid prescribing for Medicare patients are at least two-thirds black, according to census data.

Dr. Gerold Sibanda, a primary care doctor in rural Greensboro, Ala., said he viewed unequal treatment of pain in black patients as a real problem.

“l meet patients who are changing doctors because ‘I’m still in pain,’” said Dr. Sibanda, who works for Whatley Health Services. “And when I ask, sometimes they haven’t been tried on what you would think would be traditional medications — nonnarcotic, even — for whatever their pain is.”

Whatley also provides care to inmates at the Tuscaloosa County Jail, and is caught up in a lawsuit filed in May by the family of a black inmate who died of a perforated ulcer, according to the suit, after his complaints of severe pain were ignored for days. Dr. Sibanda is not implicated in the lawsuit.

Several patients, including Ms. Lewis, said they thought that doctors had mistreated them, but that it had happened because they were poor or uninsured, not because they were black.

“I don’t think it’s prejudice,” said Rita Evans, 57, a black former factory worker in Winfield, Ala., with a bulging disc in her back and a pinched nerve in her neck. “I think it’s the money.”

Ms. Evans, who often sleeps sitting up to keep immobilizing neck pain at bay, said her doctor had prescribed muscle relaxants and a nonnarcotic drug for her nerve pain. She said that she knew plenty of people who got opioids from pain clinics, but that with no income or insurance, she could not get in the door. Instead, she said, “you talk yourself through it or pray on it.”

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Beverly E. Thorn, a University of Alabama psychology professor, led a study of low-income patients to see how well group cognitive behavioral therapy relieved pain compared with only medical treatment.CreditIlana Panich-Linsman for The New York Times

Dr. Carmen R. Green, an anesthesiologist, pain medicine specialist and University of Michigan professor who has studied treatment disparities for years, said that “the role of race is more important, although race and class often interact.”

One study, in 2004, found that workers’ compensation programs spent less to treat blacks with lower back injuries, and that the treatment periods for blacks were shorter, regardless of income level.

“Our data pretty clearly say it’s a race issue,” said Raymond Tait, a pain researcher at St. Louis University in Missouri and co-author of the 2004 study. “Our take on this was that during active treatment, we believe negative stereotypes impact clinical decision-making.”

Gwendolyn Jones, a former grocery store manager in Birmingham, Ala., said she had to wait two years for back surgery, and two more to see a pain management specialist, after being injured on the job in 2008. She does not attribute the delay to racial bias, she said, but believes it led to a worse outcome.

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“I learned so much I was actually shocked,” Ms. Lewis said of her cognitive behavioral therapy. “It’s about triggering your brain to go to something else, other than the pain.”CreditIlana Panich-Linsman for The New York Times

Her disc surgery in 2010 did not work, she said, and the drugs her pain specialist has prescribed, including methadone and hydrocodone, do not help much, either.

“If they had gone ahead and done the surgery right away,” said Ms. Jones, 49, who is black, “then I may have been able to go back to work.”

Ms. Lewis, the former dollar store employee, said the best balm for her pain had been 10 weeks of group cognitive behavioral therapy, which aims to help people change how they think about pain. The therapy was part of a study of low-income patients led by Beverly E. Thorn, a University of Alabama psychology professor, to see how the therapy relieved pain compared with only medical treatment. The participants were patients at Whatley, a partner in the study, and about 70 percent were black.

According to Dr. Thorn’s preliminary findings, the group that received cognitive behavioral therapy had significantly less pain and fewer depressive symptoms afterward than a control group that got medical treatment.

“It’s about triggering your brain to go to something else, other than the pain,” Ms. Lewis said.

But the study ended last year, and Ms. Lewis’s pain remains so bad that she often relies on a cane borrowed from her aunt, dragging her right leg behind her. She recently learned that she qualified for Medicaid because she had no steady income and was caring for a teenage son. With insurance, she was finally able to start physical therapy last month.

“I feel proud of myself that I finally got something to go for,” she said, “instead of complaining and complaining about the pain, not being able to do something about it.”

A version of this article appears in print on , on Page A1 of the New York edition with the headline: Minorities Seeking Pain Relief Are Shortchanged in Treatment. Order Reprints | Today’s Paper | Subscribe